Comparing the Utility of Clinical Risk Scores and Integrated Clinical Judgment in Patients with Suspected Acute Coronary Syndrome.

Background: The utility of clinical risk scores regarding prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgment (ICJ) of the treating emergency department (ED) physician.
Methods: Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicenter study. We compared the prognostic performance of the HEART-score, GRACE-score, T-MACS, TIMI-score, and EDACS, as well as unstructured integrated clinical judgment (ICJ) of the treating ED physician (visual analogue scale to estimate the probability of an acute coronary syndrome (ACS), ranging from 0-100).
Results: Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART-score, GRACE-score, T-MACS, and ICJ (area under the curve (AUC) 0.85-0.87), but significantly lower and only moderate for the TIMI-score (AUC 0.79, p<0.001) and EDACS (AUC 0.74, p<0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96%, 87% (p<0.001), and 72% (p<0.001), respectively.
Conclusion: The HEART-score, GRACE-score, T-MACS, and unstructured ICJ of the treating physician, but not the TIMI-score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use.
(© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)